1. Behavior Intervention for Bariatric Surgery Patients: How Can Outcomes Be Improved? Melissa A. Kalarchian, Ph.D. Associate Professor of Psychiatry and Psychology

2. What do we know? u Long-term weight control is related to making and sustaining permanent changes in eating and activity u Overall, bariatric surgery is associated with significant weight loss and improvements in obesity-related comorbidities among severely overweight indiviudals

3. Bariatric Surgery u Bariatric surgery appears to be the most effective treatment for class III obesity (BMI > 40) u Also recommended for individuals with class II obesity (BMI 35-39.9) and serious comorbid risk factors (e.g., CHD, type 2 diabetes) NIH Consensus Development Panel, 1991

4. 10 Year Weight Changes in SOS Study (Sjostrom et. al., 2004, NEJM)

5. Types of Procedures u Restriction only (e.g., Lap-Band, sleeve gastrectomy) u Restriction plus malapsorption (e.g., gastric bypass, biliopancreatic diversion)

6. Roux-en-Y Gastric Bypass

7. Lap-Band

8. Surgical Treatment Outcomes u In a large meta analysis (N > 22,000), overall weight loss was 61% of excess weight (Buchwald et. al., 2004, JAMA ) u Improvements or resolution in –Diabetes (86%) –Hyperlipidemia (70%) –Hypertension (79%) –Obstructive sleep apnea (84%)

9. Overall Outcomes can Obscure Individual Variability u A significant minority of patients will experience inadequate weight loss or significant weight regain u For example, in the SOS study, 25% of patients had lost less than 10% of initial body weight, and 9% had gained weight at 10 year follow-up

10. Behavior Intervention may Improve Outcomes PhaseBody WeightBehavioral Targets I: PreoperativeEnergy imbalance results in development of clinically severe obesity (BMI > 40)  Decision making  Preparation for surgery II: PostoperativeCaloric expenditure exceeds intake, resulting rapid initial weight loss; weight loss continues for a discrete period  Compliance with dietary and lifestyle recommendations from health care team  Adaptations to rapid weight loss III: Longer-term AdjustmentPatients exhibit variability in outcomes; most maintain a significant weight loss, but also remain obese (BMI > 30)  Maintenance of changes in eating and behavior  Psychosocial adjustment  Lifelong medical surveillance

11. Theoretical Model for Improving Postoperative Weight Control

12. Body Weight is not the only Target for Behavioral Intervention u Other important outcomes include –Compliance with diet and exercise guidelines –Co-morbid psychiatric disorders –Loss of control over eating u The relationships among weight, eating, exercise, and mental health are complex and reciprocal

13. Diet and Exercise u National Weight Control Registry (NWCR) data indicate that surgery patients report higher fat intake and lower physical activity than those who lost weight through non- surgical means (Bond et al., Int J Obes, 2009; Klem et al., Int J Obes, 2000) u Patients may experience greater health benefits after bariatric surgery if diet and exercise behaviors are targeted for intervention

14. Psychiatric Disorders u Psychaitric disorders are a major concern for this patient population u Bariatric surgery patients with a history of psychiatric disorders may benefit from careful monitoring and tailored intervention

15. Lifetime Psychiatric Disorders are Common Kalarchian et al., 2007, Am J Psychiatry

16. Psychiatric Disorders are Associated with Higher BMI

17. Psychiatric Disorders are Associated with Lower Physical Functioning

18. Psychiatric Disorders Predict Poorer Short-Term Outcomes u Linear regression was used to examine Mood, Anxiety, Eating and Substance disorders as predictors of postoperative weight outcomes after controlling for demographic factors (BMI, sex, age, race) u Mood and Anxiety were related to BMI change (ps <.001), but eating and substance disorders were not (Kalarchian et al., SOARD, 2008)

19. “Binge” or “Loss of Control” Eating u A growing body of literature suggests that the onset or recurrence of subjective binge eating (or loss of control over eating) is a marker of poor long-term outcome u Postoperative binge eating may be a possible target for clinical intervention

20. Postoperative Loss of Control Predicts Longer-Term Outcome White, Kalarchian et al., J Clin Psy, 2010

21. Adapting Behavior Intervention u Consider the needs of participants, type of surgery, and target outcomes. For example: –Patients travel a significant distance to seek care in surgical Centers of Excellence, and some have physical limitations so consider alternate modes of intervention delivery (e.g., telephone, Web) –Include psychoeducation specific to the surgical procedure (e.g., realistic expectations for gastric banding) –Tailor intervention techniques to the target outcomes (e.g., limiting high calorie liquids to reduce dumping and improve weight control after bypass)

22. Integrating Behavioral Intervention with Surgical Care u Include a multidisciplinary team approach, integrating behavioral intervention with routine care u Always rule out surgical causes for complications or poor outcomes before pursuing strictly behavioral intervention

23. Typical Schedule of Postoperative Care u Discharge u 2 weeks u 6 weeks u Every 2 – 3 months u Every 6 months u Annually thereafter

24. Clinical Intervention Research u Behavior intervention research in bariatric surgery is very limited u In our work, theory-driven intervention development--along with focus groups and clinical case studies--has been used to adapt standard behavior interventions to the needs of bariatric surgery patients

25. PREP vs. RENEW Intervention Delivery: PREP: One-on-one, prior to surgery RENEW: Groups for patients > 3 years after surgery Treatment Adaptations: Education and preparation for surgery Longer-term adjustment Patient Population:Candidates for surgeryPatients with sub- optimal outcomes Key research questions: Does a pre-operative intervention decrease weight before surgery and reduce complications after? Is a post-operative intervention feasible and effective for treating failure?

26. Preoperative Behavior Intervention – PREP study u RCT: 200 patients receive behavioral intervention or usual care prior to surgery –Aim 1: To determine the impact of a preoperative lifestyle intervention on weight and psychosocial outcomes before operation –Aim 2: To determine if preoperative intervention reduces surgical risks and behavior-related complications after operation

27. PREP Study Timeline Pre Post Surgery Usual Care Intervention 6 month Follow-up 12 month Follow-up 24 month Follow-up Randomization

28. PREP Model of Treatment Effects Preoperative Outcomes ↓ Body Weight/BMI ↑ Preparation for surgery Exercise Behavior ↑ Physical activity ↓ Sedentary activity Knowledge ↑ Knowledge about surgery and obesity Eating Behavior ↓ Caloric intake ↑ Nutritional quality Preoperative Lifestyle Intervention Postoperative Outcomes ↑ Compliance ↓ Behavior-related eating problems ↓ Complications ↓ Outpatient visits with conditions SURGERY

29. Postoperative Behavior Intervention – RENEW Study u Pilot: 36 patients participated in a group intervention for long-term weight loss failure –Aim 1: To describe patients who fail to lose weight or experience regain –Aim 2: To document the feasibility and preliminary efficacy of a lifestyle intervention for this subgroup of patients

30. RENEW Participants u Over age 21 u Had bariatric surgery at least 3 years ago u BMI > 30 u < 50% Excess weight loss u Medical clearance from PCP and Surgeon (including recent upper GI)

31. Modeled Weight Change in Kg Weight Change Baseline Month 6 Month 12

32. Brief Summary u Adjunct behavioral interventions may help to optimize patient outcomes in bariatric surgery u The PREP and RENEW studies are examples of pre- and post-operative behavior intervention studies u The treatments were adapted for the type of surgery, target outcomes, and needs of the participants

33. u University of Pittsburgh Obesity and Nutrition Research Center Pilot/Feasibility Study u Optimizing Lifestyle Adjustment in Weight Loss Surgery (K23 DK62291) u Preoperative Lifestyle Intervention in Weight Loss Surgery (R01 DK077102) u Behavioral Intervention for Weight Loss Failure Surgery (R03 DK078562) u Optimizing Long-term Weight Control in Bariatric Surgery (ASMBS Foundation)